Documentation Errors Related to Electronic Health Records

Ryan Bucsi Senior Litigation Analyst

Allegation

No allegations were made as these scenarios did not result in claims. 

Disposition

Practice revised its EHR policy to prevent a recurrence of these errors.

Case Summary 1

A technician copied a patient’s medication list from the paper chart to the electronic health record (EHR). Unfortunately, the technician referenced the wrong chart so the entire list of medications was incorrect. When the error was discovered, the healthy young patient became upset that another patient’s medication list had been entered into his medical record. Despite receiving a phone call and letter of apology from the administrator, the patient lost confidence in the practice and changed providers.

The group then revised its policy on medication entries to require a clinical manager to oversee and sign off on all electronic exam entries by technicians. Any errors subsequently found during audits are brought to the attention of the clinical manager and the technician at fault.

Case Summary 2

The patient’s ophthalmologist was out of the office when a prescription refill request came in. An administrative assistant at the group sent the refill request to a mail order pharmacy without first getting physician approval. Unfortunately, the prescription dosage had been entered into the EHR incorrectly so the refill request was for 0.25% Timolol instead of 0.5% Timolol as the ophthalmologist had prescribed.

When the patient received the refill, she noticed the medication bottle had a blue cap instead of the yellow cap she was used to. She called the ophthalmologist to find out why the cap color had changed, which brought the medication error to the group’s attention.

No harm was done to the patient and she was reimbursed for the cost of the medication. The administrative assistant, a longtime employee of the practice, was given a written warning for breach of the group’s policy, which required physician sign off on all refill requests.

Case Summary 3

An ophthalmologist ordered Durezol for a patient’s iritis and entered the medication into the free text area of the EHR instead of using the medication module. The scribe then sent a prescription request for Dorzolamide to the pharmacy. At a scheduled follow-up visit two days later, the technician also failed to add the prescription to the electronic medication module and copied the ophthalmologist’s order from the previous visit again into the free text area of the chart for the patient’s medications.

Three days after the follow-up appointment, the patient went to the emergency room complaining of increasing pain. The iritis had indeed worsened, and it was in the emergency room that the medication error was finally discovered. The patient chose not to return to the group practice after learning of the error.

A warning was issued to the ophthalmologist, scribe, and technician. The ophthalmologist was credentialed with a hospital system that required use of a different electronic prescribing system from the group’s EHR. To the ophthalmologist, entering the medication in the group’s EHR as well as the hospital’s system seemed to be an unnecessary duplication of effort. Had she done so, however, the discrepancy most likely would have been caught and the patient would not have ended up in the emergency room.

Risk Management Principles

Electronic health records promise faster and more consistent data entry with the goal of improving patient care and safety. Redundancies are built into the system to provide opportunities to double check entries and catch discrepancies before costly mistakes are made. Still, errors do occur and inaccuracies in EHR documentation can have negative consequences for the physician-patient relationship. None of the scenarios discussed here resulted in a professional liability claim or significant harm to the patient, yet two patients chose not to return to the practice and terminated their care with the ophthalmologist.

The use of electronic health records over paper records can be a double-edged sword when claims do arise. They can either be used by the defense to support the physician’s care or by the plaintiff to show a clear and undisputable record of an error.

Access to an EHR System While On-Call

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Winter 2012

A policyholder called today to get input on a difference of opinion in his group. The group has implemented an EHR system. One of the partners, who is an early and enthusiastic adaptor of technology, feels that ophthalmologists must access the EHR when handling after-hour calls for the group. Another physician, less technologically-inclined, is reluctant to carry a computer at all times and take on additional work if it is not necessary.

Q  Am I legally required to access the EHR when speaking to a patient after-hours? Does OMIC require this?

A  No. OMIC is not aware of any laws or regulations that make such access mandatory, and we have no underwriting requirements related to electronic records.

Q  Do all members of the call group have to agree on whether or not to access the records?

A  Patient safety studies have shown the value of a standardized approach in reducing the incidence of errors and improving communication. As in other areas of practice administration, such as appointment scheduling, prescription refills, noncompliance and billing, it is easier for staff if all physicians in a group handle issues in a similar fashion. Once the group reaches consensus, it would be helpful to develop a written protocol and train staff members in it. Policies need to be realistic and reflect goals that can be consistently reached. Such written protocols protect physicians from inadvertent criticism from their colleagues and staff if there are unexpected patient outcomes.

Q  What are the risks if I don’t access records?

A  During telephone conversations, the health care team does not have access to the wealth of information obtained from face-to-face communication and a physical examination of the patient.  Moreover, the patient may be a poor historian who does not know how to communicate what the problem is, or may not want to inconvenience the physician or appear to be whining or complaining. This situation is even more problematic after-hours, when the patient may be unknown to the ophthalmologist and medical records may not be available at the time of the telephone encounter. Making medical decisions on the basis of the limited information obtained over the telephone is, therefore, a risky—albeit necessary—aspect of ophthalmic practice. Indeed, OMIC claims experience confirms that inadequate telephone screening, improper decision-making, and lack of documentation all play a significant role in ophthalmic malpractice claims. Negligent telephone screening and treatment of postoperative patients is especially likely to result in malpractice claims. By reviewing the record, you may find information key to the diagnosis or management of the patient, such as a patient’s allergy, test results, medication record, or history of recent surgeries. Without such information, you may inadvertently prescribe a contraindicated medication, or determine that urgent care is not needed. If the patient is harmed and sues, he or she may allege that failure to consult the record was negligent. As more and more physicians implement EHR systems, pressure may grow to access records after-hours, even though this care is generally not reimbursed by insurance companies.

Q  What else can I do to reduce the risk of telephone care?

A  First and foremost, exercise the same care when treating a patient by phone as you would during an office visit. To promote both continuity and defensibility of care: (1) gather the information necessary to assess the situation and determine the treatment plan, (2) communicate the assessment and plan to the patient, and (3) document the encounter and your decision-making process in the medical record as soon as possible after the conversation, by the next business day at least.

Q  Can’t I just get the information from the patient?

A  You may be able to if you ask enough questions and have a patient who can reliably answer them. At other times, you may have to make a decision with limited or inaccurate information. In the absence of records, OMIC recommends using an after-hours contact log that prompts you to ask detailed questions about the current complaint and prior care. The form also serves to document the conversation and can be faxed to the patient’s regular physician to promote continuity of care.

Q  If I do access the record, how thoroughly do I need to review it?

A  There is no easy answer. You face a similar situation when you take over care from another physician, or see a partner’s patients in the office. The standard to which you will be held is that of a reasonably prudent physician. Obviously, you will not have time to review the entire record. At a minimum, you would want to check allergies, medication history, and recent procedures. Reading notes from the latest visits or phone calls might help you determine if the patient’s condition is changing or worsening. Document which records you reviewed in order to assess the patient. To facilitate after-hours call, it would help if the record contained a front sheet with key information.